Provider Demographics
NPI:1083222392
Name:RIVERA, ANGEL IVAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:IVAN
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7606 MARINETTE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-4750
Mailing Address - Country:US
Mailing Address - Phone:713-419-9775
Mailing Address - Fax:
Practice Address - Street 1:2780 HIGHWAY 365 STE C
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2191
Practice Address - Country:US
Practice Address - Phone:409-332-4701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36381122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist